Building integrated falls and bone health care pathways including Telehealth – A Scottish Perspective #Actiononfalls September 2019 Lianne McInally Acting Head of Improvement NHS Lanarkshire

• Population c 658,000 • Scotland in microcosm

– Rural & Urban

• Declining heavy industry/high unemployment /increasing indices of ill health

• New towns / increasing elderly population & increasing indices of long-term limiting illness exceeding national trends

This is Lanarkshire

• Urban areas collocated to three Acute Hospitals • South Lanarkshire 1.71 people per hectare • North Lanarkshire 6.83 people per hectare • Rural supported by Community Hospitals due to distance

Estimated 38000 people over 65 in Lanarkshire will fall each year.

• 73% of all fall admissions are via A&E.

• Average stay due to fall is 14 days.

• 291 individuals (66%) return home after their fall; the rest are either transferred, delayed or pass away.

• 22% of fall admissions result in a delayed discharge – average length of delay is 6 days.

• 37 individuals pass away within three months of their fall; 19 of them in the same falls admission.

Source:ISD 2019

Costs associated with falls and fractures (3 months pre and post)

Service No. Individuals

No.

Attendances /

Admissions

Total Cost Total

Beddays

A&E 319 323 £36,596

Non-Elective 442 451* £2,842,209 6,773

Delayed

Discharge 99 99 570

Source:ISD 2019

#Actiononfalls

Chief Medical Officers Guidelines UK 2011 Start Active Stay Active

#Actiononfalls

Muscle Nerve 1993, 16:294

#Actiononfalls

Source: UK Physical Activity Guidelines 2019 p16

#Actiononfalls - Function and Frailty

Clegg et al, Lancet, 9868(381) 753

Harvey J, 2018,

Sedentary Blethering

Scotland’s Vision & Ambitions (Draft Strategy): Our shared vision is of a Scotland where more people live free from harm and social isolation from falls Our ambitions Build resilience at population level: work together across sectors and with individuals and communities to enable more people to maintain or build their resilience and reduce their exposure to risk factors for falls and osteoporosis. Take action earlier: work together across sectors and with individuals and communities, to cultivate a shared responsibility for recognising and exploiting valuable opportunities to take earlier preventative action – when signs of frailty and functional decline are first recognised, and, after one fall or fragility fracture to prevent another. Target evidence-based and personalised support: collaborate to deliver evidence-based falls and fragility fracture prevention interventions for those at highest risk and with complex needs, with a focus on supporting people to achieve outcomes that are important to them. An integrated approach: work more closely together across the system and with individuals and communities to design, plan, fund and deliver falls and fragility fracture prevention and management, and frailty prevention, identification, management and care.

Falls Pathway Stage 1: Building resilience at a population level

Falls Pathway Stage 2: Take action earlier

Falls Pathway Stage 3: The right response and care at the time of a fall and the right care thereafter

Falls Pathway Stage 4: target evidence-based and personalised support

Check •Lying & Standing BP

•Manual Heart Rate

•Blood glucose

Consider •Referral to DN, ICST

•If loss of

consciousness ref to

GP

•Discussing with

specialist falls service

Dizziness /

Blackout

Complaints of

Dizziness, Light-

headedness or

“just went down”

Medications

Polypharmacy

High Risk

Drugs (See appendix2)

Check •If any dizziness light-

headedness, visual

disturbance,

hallucinations

•Any recent changes to

medications

•Compliance Use

•Use of over the counter

medication

Consider •Pharmacy / GP review

of medication

•Referral for compliance

aids

•Social work for

medication prompt

Mobility & Balance

Unsteady gait/

balance/

Muscle weakness/

Fear of falling

Check •Need for walking aid

•Appropriate walking aid

being used

•Condition of current

walking aid.

•Splints/prosthesis

correctly fitted.

•Assessment of balance

Consider •Referral to Community

physiotherapist (house

bound) / out-patient

physiotherapy dept/

CARS/ICST

•Discussing with specialist

falls service

•Referral to NHS Falls Class

or Leisure class

Continence

Incontinent of

urine & / or

Faeces

Check •Urinalysis

•Clothing easy

loosened

•Catheter bags

secured to leg

•Changes to

elimination habits

Consider •Referral to DN or

Practice Nurse for

continence

assessment

•Provision of

commode

Vision & Hearing

Visual or Hearing

Impairment

Check •If vertigo symptoms (room

spinning)

•Hearing aids fitted

correctly & working

•Wearing current

prescription glasses

•Good lighting

Consider •Optician for eye test

•Local domiciliary opticians

•Discourage use of multifocal

glasses- provide visual leaflet

•Referral to Social Work

Sensory Impairment Team

•Practice nurse for ear

assessment

LEVEL 2 – Falls Assessment Guidance Notes

Check •Osteoporosis risk

factors

•If had Dexa Scan

•Prescribed bone

medications

•Compliance with bone

medication

•Calcium rich diet

Consider •Referral to Osteoporosis

Service

•Lifestyle/ dietary advice.

•Referral to Community

physiotherapist (house

bound) / out-patient

physiotherapy dept

•Referral to leisure class

Bone Health

Osteoporosis

/ Previous

Fractures

Feet / Footwear

Foot pain /

discomfort

Splints /

Prosthesis

Check •Appropriate footwear

•Skin colour / sensation /

movement

•Compliance with Splints

/ prosthesis

•Appliances are fitted

properly

Consider •Referral to podiatry

•Referral to Orthotics

•Footwear / foot care

advice - provide foot

care leaflet as

appropriate

Cognitive

Impairment

New / increased

confusion

Known cognitive

impairment

Check •For signs of infection

•If any recent

medication changes

•Cognitive Assessment

Consider •Referral to Community

Mental Health Teams or

GP

•Refer to Social Work

Dept. for assistive

technology assessment

Environment

Is the

environment

safe / suitable?

Check •Transfers (e.g. bed,

toilet, chair)

•Safety on internal /

external stairs

•Lighting suitable

•Home hazards

•Pathways around

home clear

Consider •Referral to OT (CARS

/ ICST / Day hospital)

•Referral to Social

Work Dept

•Making Live Easier for

equipment provision.

Frailty

Evidence of

weight loss or

poor oral

intake

Check •Weight

•Dentition

•Ability to make meals

Consider •Referral to dietician

for nutritional

assessment.

•Referral to Dentist for

issues relating to

dentition

•Referral to OT and

Social Work Dept.

LEVEL 2 - Falls Assessment Guidance Notes (continued)

Lanarkshire Falls Pathway

Specialist falls service and falls

clinics

Falls Register, ICST; CARS; Social

Work Staff (Home Support Managers,

Community OT, Care Managers); Day

Services; Care Homes; Community

Physiotherapy; Day Hospital; Hospital at

Home; new acute falls documentation

Scottish Fire & Rescue; Scottish

Ambulance Service; GPs; Podiatry;

Orthotics; MSK Physiotherapy;

Voluntary groups; Self

Referral,Fracture Liaison Service

Level 1 & 2 of the Community Falls Pathway are supported by a comprehensive programme of Falls

Awareness & Pathway Training.

Outcomes

Review of clients 6 months post intervention:

83% patients reported no further falls.

A/E attendances due to falls reduced by 60%.

Hospital admissions due to falls reduced by 71%.

9400 people have had a falls conversation and interventions

1300 staff trained to have level 1 conversation & level 2 assessment

0

200

400

600

800

1000

Falls register quarterly referrals 2015 - present Falls register referrals

450% increase

• https://www.youtube.com/watch?v=nKGk_55kpUA

@liannemcinally1 #thinkactivity

#frailty5 #actiononfalls

#stopthedropbp

Contact

lianne.mcinally@lanarkshire.scot.nhs.uk